Coronial
VICcommunity

Finding into death of Jorgen Bottern

Deceased

Jorgen Bottern

Demographics

86y, male

Date of death

2021-07-15

Finding date

2023-08-28

Cause of death

carbon monoxide poisoning

AI-generated summary

An 86-year-old man with recent stroke, declining mental health, and expressed suicidal ideation died by carbon monoxide poisoning. He was assessed in hospital ED, deemed not to meet Mental Health Act criteria, and discharged to community care with daily follow-up planned. Within three weeks, he died by suicide. Key clinical lessons: (1) older men aged 85+ have the highest suicide rate in Victoria—this demographic requires specific, targeted suicide prevention strategies; (2) discharge planning for high-risk patients requires robust follow-up mechanisms and clear communication with carers; (3) healthcare systems lack adequate targeted mental health services for older people despite known high suicide rates; (4) recognition of transition points and loss of independence as significant suicide risk factors in older males.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrygeneral practiceemergency medicine

Error types

system

Clinical conditions

suicidal ideationdepressionstroke with residual left-sided weaknessanxiety regarding health and independence

Contributing factors

  • suicidal ideation
  • depression and mental health decline
  • stroke with residual weakness and associated concerns about independence
  • inadequate targeted mental health services for older people
  • loss of spouse six years prior (2009)
  • concerns about further stroke and impact on independence
  • lack of comprehensive suicide prevention strategy for older Victorians

Coroner's recommendations

  1. Develop and implement a comprehensive articulated strategy to address suicide in older people, separate from general suicide prevention strategies
  2. Include in any suicide prevention strategy for older people both services for the older person and training and support for carers (paid and unpaid)
  3. Monitor implementation of Victoria's new Suicide Prevention and Response Strategy (SPARO) to ensure specific initiatives are tailored to the needs of older Victorians, particularly older men
  4. Expand availability and uptake of national suicide prevention programs for seniors (such as the Anglicare National Suicide Prevention for Seniors online course) targeting aged care workers, retirement living staff, pharmacists, geriatricians, GPs, and unpaid carers
  5. Ensure mental health services address unique risk factors in older people: loss of independence, transition points (retirement, entry to aged care), chronic pain, and bereavement
  6. Improve continuity of care and navigation between support, care, and treatment systems for older people with mental health needs
  7. Continue monitoring suicide rates for older Victorians through monthly suicide data reports
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

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